Section 3923.28 | Outpatient coverage for mental or emotional disorders.
(A) Every policy of group sickness and accident insurance providing hospital, surgical, or medical expense coverage for other than specific diseases or accidents only, and delivered, issued for delivery, or renewed in this state on or after January 1, 1979, and that provides coverage for mental or emotional disorders, shall provide benefits for services on an outpatient basis for each eligible person under the policy who resides in this state for mental or emotional disorders, or for evaluations, that are at least equal to five hundred fifty dollars in any calendar year or twelve-month period.
(1) The services shall be legally performed by or under the clinical supervision of any of the following:
(a) A physician authorized under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery;
(b) A psychologist licensed under Chapter 4732. of the Revised Code;
(c) A licensed professional clinical counselor, licensed professional counselor, independent social worker, or independent marriage and family therapist licensed under Chapter 4757. of the Revised Code;
(d) A clinical nurse specialist or certified nurse practitioner licensed under Chapter 4723. of the Revised Code whose nursing specialty is mental health.
(2) The services may be performed in an office, in a hospital, or in a community mental health facility so long as the hospital or community mental health facility is approved by the joint commission, the council on accreditation, or the commission on accreditation of rehabilitation facilities.
(B) Outpatient benefits offered under division (A) of this section shall be subject to reasonable contract limitations and may be subject to reasonable deductibles and co-insurance costs. Persons entitled to such benefit under more than one service or insurance contract may be limited to a single five-hundred-fifty-dollar outpatient benefit for services under all contracts.
(C) In order to qualify for participation under division (A) of this section, every facility specified in such division shall have in effect a plan for utilization review and a plan for peer review and every person specified in such division shall have in effect a plan for peer review. Such plans shall have the purpose of ensuring high quality patient care and effective and efficient utilization of available health facilities and services.
(D) Nothing in this section shall be construed to require an insurer to pay benefits which are greater than usual, customary, and reasonable.
(E)(1) Services performed under the clinical supervision of a health care professional identified in division (A)(1) of this section, in order to be reimbursable under the coverage required in division (A) of this section, shall meet both of the following requirements:
(a) The services shall be performed in accordance with a treatment plan that describes the expected duration, frequency, and type of services to be performed;
(b) The plan shall be reviewed and approved by the health care professional every three months.
(2) Payment of benefits for services reimbursable under division (E)(1) of this section shall not be restricted to services described in the treatment plan or conditioned upon standards of clinical supervision that are more restrictive than standards of a health care professional described in division (A)(1) of this section, which at least equal the requirements of division (E)(1) of this section.
(F) The benefits provided by this section for mental and emotional disorders shall not be reduced by the cost of benefits provided pursuant to section 3923.281 of the Revised Code for diagnostic and treatment services for biologically based mental illnesses. This section does not apply to benefits for diagnostic and treatment services for biologically based mental illnesses.
Available Versions of this Section
- July 10, 2014 – House Bill 232 - 130th General Assembly [ View July 10, 2014 Version ]